The Ebola Epidemic in Liberia and Its Effects on the Church & Population

1. The Ebola Epidemic in LiberiaandIts Effects on the Church & Population Dr. Paul Mertens Oct. 18, 2014

2. COUNTRIES OF THE CONTINENT OF AFRICA(54 in all)Note Liberia is the small country (in yellow) on the west coast of Africa at the bottom of Africa’s western bulge. Founded by US freed slaves returning to Africa in 1821. It has an estimated population of about 3,800,000. S.Sudan

3. The Republic of Liberia For those who do not know Liberia: Liberia emerged from a 14-year civil war in 2003 with the country ruined Guinea Sierra Leone • Liberia is located on the west coast of Africa • Declared a republic in 1847 • Approximately the size of the state of Kentucky or half the size of Minnesota • It is within the tropical rainforest belt of Africa • The capitol is Monrovia, named after U.S. President Monroe • Population ~95% indigenous Ivory Coast Atlantic Ocean

4. Living Organisms • What are the characteristics of living organisms? • They take in nutrients (i.e., “eat”) • Most take in oxygen to combine with food • They metabolize • They grow • They reproduce

5. What are the characteristics of Viruses? Are viruses “living” organisms? Characteristics: • Do not eat • Do not breathe • Do not metabolize • Do not grow • Do not (of themselves) reproduce • Hence, they are not really “living organisms” as we usually define “life” (some call them a different form of life without the usual characteristics) • They are extremely small complex organic chemical structures with a protein core containing an RNA or DNA genetic code

6. But viruses have the ability to enter cells of living organisms • Each virus can enter only cells of specific species • And the genetic-type code (RNA or DNA) which the virus contains takes over the cell and causes the cell to make copies of the virus which has entered it (instead of doing what the cell is supposed to normally be doing) • Now if a cell stops doing much of what it is supposed to do, it becomes “sick” • And if severe enough, the sick cell dies

7. What are Viral Hemorrhagic Fevers?(From the CDC’s Special Pathogens Division) • Viral hemorrhagic fevers are severe viral illnesses affecting many body systems • Cause damage to the vascular system causing blood and fluids to leak out of the capillaries • Usually also damage the body’s ability to produce clotting factors to stop bleeding • Because they often cause bleeding, they are called Hemorrhagic Fevers

8. Viral Hemorrhagic Fevers • Viruses come in 2 types: RNA and DNA viruses • All severe viral hemorrhagic fevers are RNA viruses • There are 4 major groups of these hemorrhagic fever viruses: • Arenaviruses • Flaviviruses • Bunyaviruses, and • Filoviruses

9. Common features of hemorrhagic viral illnesses • Besides being RNA viruses, all are covered, or enveloped, in a fatty (lipid) coating • Their survival is dependent on an animal or arthropod (insect or tick) host, called the natural reservoir—usually they don’t seriously injure host • The viruses are geographically restricted to the areas where their host species live • Humans are not the natural reservoir for VHFs • Humans are infected when they come into contact with infected animal hosts, or bitten by mosquitoes or ticks carrying the virus from animals to humans

10. However, with some VHF viruses, after the accidental transmission from the animal host, humans can transmit the virus to one another • Human cases or outbreaks of hemorrhagic fevers caused by these viruses occur sporadically and irregularly • The occurrence of outbreaks cannot be easily predicted • With a few noteworthy exceptions, there is no cure or established drug treatment for VHFs

11. The 4 Viral Hemorrhagic Fever (VHF) Groups 1) ARENAVIRUSES: • Lassa Fever-West Africa –especially Nigeria thru Guinea (other Arenavirus illnesses S. America) • Less ill initially than with Ebola, & Ribavirin helps • Mortality about 10% • Young rats do not become ill with Lassa virus • Curran LH epidemic 1972 Host: Multimammate rat (Mastomys natalensis) • Humans infected from rat excrements on food or from preparing rats for cooking • No vaccine available

12. 2) FLAVIVIRUSES Yellow Fever virus may circulate in the monkey population in forests Both viruses are spread by the bite of the Aedes aegpti mosquito • Yellow Fever—Tropical Africa, Asia & S. America • Mortality approx. 10% • Vaccine available & good • Used to occur in USA—In 1793—killed 10% of population of Philadelphia • Also Mississippi & Ohio R. valleys & New Orleans • Dengue—Tropical areas- causes bleeding much less frequently than Yellow Fever

13. 3) BUNYAVIRUSES: Rift Valley Fever—Africa Host: Domesticated animals Crimean-Congo HF— Host: Ticks Hantavirus--”Hemorrhagic Fever with Renal Syndrome” Eurasia, Africa, Americas Hosts: Rodents such as the Deer mouse Deer mice Photo from Google Ticks Photo: James Occi

14. 4) Filoviruses--Two similar hemorrhagic fever viruses with high mortality rates: 1) Marburg—Has caused epidemics in East, Central and South Africa. First identified in Marburg, Germany in 1967 from an outbreak when researchers developed disease from ill African monkeys. 2) Ebola—Caused 12 small epidemics in East and Central Africa previously – first recognized in the Congo in 1976. But no previous outbreaks in West Africa. Note the elongated shape of the Ebola virus as viewed under an electron microscope—looks like a filiment Both viruses look the same & both illnesses are similar • Host for both of these viruses—African fruit bats

15. . Fruit bats of the Pteropodidae family -- considered to be the natural host of the Ebola virus Yambuku is a village situated near the Ebola River (the river from which the disease takes its name) Above: Fruit bat in flight (Source:telegraph.co.uk) Left: Fruit bats resting on a branch (Source:scienceblogs.com) Ebola first recognized in 1976 in 2 simultaneous outbreaks: • In Nzara, Sudan and • In Yambuku, Democratic Republic of Congo (Zaire)

16. Ebola Disease Initial Symptoms: Sudden onset of Fever, Headache, Muscle pain, Sore throat & Intense weakness Then Vomiting & Diarrhea Later: Impaired Liver & Kidneys Internal & external Bleeding Sometimes Rash also occurs Poster from US CDC • Ebola is a zoonotic (animal) viral hemorrhagic fever • We believe it normally lives in fruit bats of the Pteropodidae family • But spreads from bats to infect other animals

17. Key facts--WHO • Ebola Virus Disease (EVD), formerly known as Ebola Haemorrhagic Fever, is a severe, often fatal illness in humans. • EVD outbreaks have a case fatality rate of up to 90%. • EVD outbreaks occur primarily in remote villages in Central and East Africa, near tropical rainforests. • The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission. • Fruit bats of the Pteropodidae family are considered to be the natural host of the Ebola virus. (Pigs have also been questioned as possibly being a natural Ebola host.) • Severely ill patients require intensive supportive care. No licensed specific treatment or vaccine is available for use in people or animals as yet.

18. The Transmission of Ebola Virus • The virus spreads from fruit bats to animals (perhaps by eating bits of fruit the bats drop?) • Then animals to other animals, or to humans • And then from humans to other humans • Humans seem to contract it from infected animals (or fruit bats) by handling the ill or recently dead animals, or preparing them for eating (often by skinning and cutting them up for cooking) • But it is most often contracted from coming in contact with the body fluids of sick humans (tears, saliva, sweat, vomit, urine, diarrhea, blood) especially when caring for them, or burying them

19. Incubation period • The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is 2 to 21 days—average 13 days • So a person who has been exposed should be isolated for 21 days—if he does not become ill in 21 days, he is not developing Ebola from that exposure

20. CDC Recommendations to Prevent Spread Disinfect homes of the dead and the sick (Use diluted 1:10 Clorox—releases chlorine) A nurse with Medecins Sans Frontieres examines a patient in the intake area at a centre for victims of the Ebola virus in Guekedou (source:thestar.com) • Prompt isolation of the sick • Prompt disposal of victims bodies • Trace all contacts of ill patients—isolate and treat if any sign of illness

21. Recommendations (continued) • Avoid eating animal meat (especially bush meat) during an epidemic • But Fish meat is o.k. • Protective clothing for health care workers & anyone handling infected animals is absolutely necessary • Wash hands with soap frequently (soap and alcohol-based hand sanitizers disrupt the viruses lipid envelop)

22. Where did this epidemic start? • Started In Gueckedou, Republic of Guinea • This is the area where the borders of Guinea, Sierra Leone, & Liberia all come together • Rural, but fairly large population • People pass back and forth across the porous borders to trade goods and produce Map-About Jan 2014-source: amanidc.org Atlantic Ocean Foya Freetown

23. How did this Ebola epidemic start? In trying to answer this question, MSF was able to trace back the history of illnesses and deaths to a 2-year-old boy in the Gueckedou area (Meliandou) who died with a fever Dec. 6, 2013 A week later, it killed the boy's mother, then his 3-year-old sister, then his grandmother All had fever, vomiting and diarrhea, but no one knew what had caused them to become ill and die

24. A health worker carried it to still another, where he died, as did his doctor • They both infected relatives from other towns • It was thought the illnesses were severe malaria, or typhoid, or cholera • When bleeding was noted, Lassa Fever became suspect • It was nearly 3 months before the cause of the increasing number of deaths was recognized as the Ebola virus • Ebola had never been seen in West Africa previously • Two mourners at the grandmother's funeral took the virus home to their village

25. And cases were occurring in the Foya area of Lofa County, Liberia, and in Sierra Leone • These are three of the world's poorest countries, recovering from years of political dysfunction and civil war (From a report by The New York Times) • By the time Ebola was recognized in March, dozens of people had died in eight Guinean communities

26. Ebola had not previously occurred in this region of West Africa Note the location of Liberia and this Ebola outbreak on the continent of Africa (source: globalnews.ca) Ebola has occurred in Sudan Uganda Zaire Gabon & Ivory Coast (1 research case)

27. Treatment of Ebola Although Ebola has a high mortality rate and there are no specific meds and no vaccines, proper supportive care can save many lives Note the isolation clothing protecting health workers and the IV fluid line for correcting dehydration in this MSF treatment unit in Guinea (source: catholic.org) • Dehydration must be corrected & prevented • Electrolytes must be balanced correctly • Hypoglycemia must be avoided • Secondary bacterial infections require treatment • With such help, about half of the patients will recover

28. Protective Equipment for Medical Personnel Note these medical personnel at an isolation ward in Guinea (source: africare.org) They are wearing protective clothing to prevent developing Ebola: • Caps • Goggles or face shields • Masks • Gloves • Protective gowns—impervious to fluids • Shoe covers

29. Protecting Medical Personnel In many cases across Africa, medical personnel treating infected patients often fail to wear the proper protection Cleaned and decontaminated gloves and boots being dried in the sun for reuse (Clorox and sunlight kill most viruses) (source: news.yahoo.com) • Masks, gloves, face shields and protective clothing are often not available • This puts health care workers at great risks, aiding the spread to them of the Hemorrhagic Fever • If needles are not disposed of properly, & someone comes in contact with the infected needle, there lies another potential risk of spreading the disease

30. Hemorrhagic bullae in an Ebola patient As capillary fragility increases and clotting factors decrease, many Ebola patients develop bleeding. This is an ominous sign. Ebola with Hemorrhagic blisters (source: umuseke.rw) Bleeding may occur from: • Injection and IV sites • Subcutaneous areas • Gastrointestinal tract • Other areas Most of the patients that develop hemorrhage die

31. By the first week of May 2014, Liberia had seen no new cases of Ebola for nearly 4 weeks and new cases in Guinea were decreasing • The Ebola epidemic seemed to be coming to an end—no new cases in Liberia for 41 days as May was closing • Unfortunately the situation worsened in June with an outbreak in Monrovia (the suburb of Bushrod Island with Redemption Hospital) from an individual exposed in Sierra Leone • Also more cases started occurring in Lofa County

32. Ebola Spreads to Monrovia As of June 27 Monrovia had had 11 cases, all of whom died In late May a lady exposed to Ebola in Sierra Leone came to Bushrod Island and infected a household with the virus. Four persons in the household became ill. Ebola patients sought care in Redemption Hospital. All died, and a nurse and doctor giving care became ill and died. Frightened patients with other illnesses and worried hospital personnel abandoned the hospital, leaving empty beds.

33. The Capital, Monrovia Contact surveillance is continuing and isolation units were set up at the JFK Medical Center & ELWA Hospital (picture source: dailymail.co.uk) After Ebola reached Bushrod Island in late May, 2014 it spread to the rest of the capitol. Monrovia, with its suburbs, is a crowded city of 1.5 million people • Such a crowded city makes it easy for the virus to spread from person to person • MOHSW has been informing the public of the symptoms & teaching how to prevent spread, but it is spreading fast

34. Ebola in the West Point Slum 1 mile West Point is a very poor slum area without a sewer system or running water, crowded with about 50,000 people living in closely-spaced small shanties. The Mesurado River is to the west and north and the Atlantic Ocean to the west. Ebola began occurring in West Point. An old school building was used as a holding center to quarantine anyone exposed. West Point Holding Center West Point is a narrow low-lying peninsula jutting north-ward from the much larger peninsula which is Monrovia proper. Mesurado River Monrovia Atlantic Ocean

35. Monrovia’s Hospitals Close Monrovia’s hospitals closed down, including the JFK National Medical Center and Catholic Hospital John F. Kennedy National Medical Center in Monrovia People with fevers seeking help went to other hospitals in Monrovia, apparently with Malaria But a few of them had Ebola Hospital personnel became infected and a number died At first protective clothing was not in good supply Nurses refused to come to work

36. Phebe and Curran Lutheran Hospitals From Ebola crossing the border into the Foya area of Lofa Co. in March through the spread of Ebola in June, Phebe and Curran Lutheran Hospitals had escaped the virus and were functioning Phebe Mission Hospital near Gbarnga in Bong County • In mid-July an ill lady came to Phebe with a fever saying she lived locally in Gbarnga town • Ebola was occurring 170 mi. to the N.W. in Foya, and 112 mi. to the S.W. in Monrovia but not anywhere in local Bong County • Precautions for Ebola were not taken with this patient • Actually the patient was from Foya & had contracted Ebola

37. Rural Hospitals & Clinics Close Down The virus got into the Gbarnga community (Liberia’s 2nd largest city) & deaths started occurring Other rural hospitals also closed Ganta Methodist Hospital, 51 mi. north of Phebe, also closed down Hospital personnel bury one of their own • Four Liberian nurses, 1 aide, 1 Liberian doctor, and a P.A. working in Phebe ER became ill with Ebola • Only the doctor managed to eventually recover • Phebe closed down • Curran Lutheran Hospital became extremely cautious & would not see fevers

38. Current Status of Phebe and Curran Status of Phebe & Curran Curran Lutheran Hospital--One nurse recently developed Ebola—38 personnel exposed. Hospital cautiouly continues to operate. Needs our prayers. • Phebe reorganized with only 1 doctor and reopened only for obstetrical and pediatric admissions late August • Many nurses were afraid to work • Finally Phebe opened all hospital services Sept. 15 • Curran Hospital continued to operate with all services with only 1 doctor, but does not admit suspected Ebola

39. Present status Phebe & Curran mission hospitals Global Health Ministries has shipped: Phebe OR-Staff in protective gowns, masks & gloves--GHM • 2 air freight – protective gear • 40’ sea freight PPEs & other • 40’ sea-food with Iowa • 3rd air freight & 2nd sea freight protective equip. & supplies planned • Collected supplies & food from Liberian community in process • More food & supplies planned

40. Personal protective clothing from GHM at Phebe Hospital

41. Church leaders also succomb Sis Jartu would place her palms on the stomach, or at times the forehead, of the sufferer she visited. Then she’d speak to the Holy Spirit and request a heavenly intervention. The congregation of Bethel Heart of Faith Church in Joe Blow Town, Liberia, grieves its losses in late August. • “Sis” Jartu Kerkulah was in the floral-print chair in her living room when the burial team in biohazard suits found her. Behind her was a bulletin board with snapshots of some of the people who had enriched her life of 46 years, a list that included her four children, her siblings, and friends from her Pentecostal church. An open prayer book lay face-down on her armrest. A toy fire station rested on the linoleum floor beside her feet. • “She was a prayer warrior,” recalled her friend, Retta Livingstone Wahid. • She often prayed for the sick.

42. Effects on the Lutheran Church of Liberia No churches or church institutions have escaped from the anguish and problems caused by Ebola. Catholic Hospital had 6 staff die, including the administrator and an elderly Spanish priest, and it remains closed. The Ganta Methodist Hospital remains closed. Trinity Lutheran Church in the New Matadi Suburb of Monrovia • Two LCL pastors, 1 deacon, & 1 missionary from India died from other illnesses when they could not obtain medical help • Some church leaders and many parishioners have also died from Ebola or other illnesses

43. Shortage of Food The main food staple in Liberia is rice, which is grown locally but not in sufficient quantities. Cassava is the second (less used) staple. This thatch lean-to shelters the women and children from the rain and sun as the rice is growing. They drive away birds and small animals that would eat the growing rice. • The Foya area of Lofa Co., epicenter of the Lofa epidemic is the largest rice-growing area • There will be less rice harvested this year • Even in good years, Liberia depends on imported rice to survive • Less ships are coming due to the epidemic and sea quarantine of ships • A food crisis is developing • Apparently some patients that might have recovered have died from lack of food

44. Liberian Ebola Cases & Deaths per Period Period: Cases Deaths HCW Cumulative cases deaths cases deaths Mar – July 2 100 61 10 8 100 61 Jul 3 – Aug 3 398 203 53 30 498 264 Aug 3- Sep 3 1365 875 90 38 1863 1078 Sep 3 - Oct 4 2058 1121 37 16 3921 2199

45. WHO Situation Report Oct. 15 • Cumulative Cases Liberia 4249* • Cumulative Deaths Liberia 2458* • Cum. Cases all 3 Countries 8997 • Cum. Deaths all 3 Countries 4493—will exceed 4500 deaths by Oct 18 & 9000 cases * Liberian data incomplete • "It is clear, however, that the situation in Guinea, Liberia, and Sierra Leone is deteriorating, with widespread and persistent transmission of Ebola Viral Disease."

46. World Health Organization—Aug 28, 2014 • If the world community of nations responds strongly and appropriately to the Ebola epidemic the West African Ebola epidemic it will take at least 6 months to bring it under control • The Ebola epidemic in West Africa could afflict more than 20,000 people before it is brought under control

47. Jerome R. Corsi, Harvard Ph.D—report in WND His chilling report just released Sept. 6 says: Developing this report, research asst. Francis Smart at MSU used results of Canadian researchers who proved this strain of Ebola could mutate to become capable of being transmitted between humans through breathing Burial team in Liberia in Hazmat suits carrying a body • From an econometric simulation model • Based on the assumption that the World Health Organization & others with present anemic response will be unable to control the Ebola outbreak in West Africa • Simulation model predicts 1.2 million people will die from Ebola disease in the next six months

48. What can we do? • Pray-God is not limited • Encourage our government to actually staff some field hospitals they are setting up • Contribute: • Global Health Ministries • Medical Assistance Programs (MAP) Internat. • SIM/Samaritan’s Purse • MSF

49. Deaths Among Health Workers As of mid-October 201 Liberian health workers have developed Ebola and 95 have died. Usual causes: 1) Insufficient protective gear or improper use, and 2) Failure to recognize Ebola and take precautions

50. Projected Deficits of Needed Protective Clothing and Equipment Protective clothing and necessary equipment are still in short supply and further donated shipments urgently needed